741485
research-article2017
HPPXXX10.1177/1524839917741485Health Promotion PracticeMcCullough et al. / PERCEPTIONS OF TOBACCO CONTROL MEDIA CAMPAIGNS
Understanding Stakeholder Perspectives
Perceptions of Tobacco Control Media Campaigns
Among Smokers With Lower Socioeconomic Status
Anna McCullough, MSW, MSPH1
Clare Meernik, MPH1
Hannah Baker, MPH1
Kristen Jarman, MSPH1
Barbara Walsh, BS2
Adam O. Goldstein, MD, MPH1
People with low socioeconomic status (SES) in the
United States have disparately high rates of smoking and
experience disproportionately high burdens of smokingrelated disease. Tobacco control media campaigns are a
critical strategy for reducing tobacco use prevalence, but
evidence is mixed about the optimal use of mass media
to reach and promote tobacco use cessation among people with low SES. Improved understanding of the factors
influencing how low-SES tobacco users evaluate tobacco
control media campaigns may inform development of
more effective messages and strategies. Focus groups
with primarily low-SES smokers in Connecticut were
conducted, finding that participants had seen many
tobacco control television ads that used graphic imagery
and testimonials, but participants voiced two main
themes that limited ad effectiveness: (1) skepticism about
the content of ads, the role of the tobacco industry and
the government in sponsoring the ads, and the safety and
efficacy of cessation supports; and (2) barriers to quitting
such as stress, social contexts, and addiction that participants perceived as being underappreciated in the
context of the ads. Tobacco control media campaigns
targeting low-SES tobacco users may need additional
messages, tools, or refinements to more optimally motivate this group to make quit attempts.
Keywords:
tobacco; tobacco cessation; media campaigns; socioeconomic status; health
communication
Health Promotion Practice
July 2018 Vol. 19, No. (4) 550–559
DOI: 10.1177/1524839917741485
© 2017 Society for Public Health Education
550
Introduction
>>
Overall prevalence of tobacco use has decreased in
the United States, yet rates remain disproportionately
high among people with low socioeconomic status
(SES). The prevalence of any tobacco use among adults
is estimated at 21.3% overall, with higher rates among
adults with a GED (50%) and adults with annual
income less than $20,000 (32.2%; Hu et al., 2016).
People with low SES smoke more heavily than those
with higher SES (Hiscock, Bauld, Amos, Fidler, &
Munafò, 2012), which contributes to increased risk of
tobacco-related diseases (Clegg et al., 2009; Mucha,
Stephenson, Morandi, & Dirani, 2006). While tobacco
users with low SES are as likely to make quit attempts
as those with higher SES, they have lower rates of success (Kotz & West, 2009) and are more likely to make
unaided quit attempts (McCarthy, Siahpush, Shaikh,
Kessler, & Tibbits, 2016). Higher use and lower cessation success rates may be a result of unique challenges
faced by tobacco users with low SES, including tobacco
industry targeting (Hiscock et al., 2012), more prosocial smoking cues (Paul, Turon, Bonevski, Bryant, &
1
University of North Carolina at Chapel Hill, Chapel Hill, NC,
USA
2
Connecticut Department of Public Health, Hartford, CT, USA
Authors’ Note: Focus groups were funded by the Connecticut
Department of Public Health. Findings and ideas presented in
this article are those of the authors and do not represent the
Connecticut Department of Public Health. Address correspondence
to Clare Meernik, 200 N. Greensboro Street, CB #7424, Carrboro,
NC 27510, USA; e-mail: cmeernik@email.unc.edu.
McElduff, 2013), less access to workplace-based smokefree policies or smoking cessation resources (Ham et al.,
2011), self-exempting beliefs about the effects of tobacco
use (Oakes, Chapman, Borland, Balmford, & Trotter,
2004), high stress and use of smoking as a perceived
stress management tool (Hiscock et al., 2012), higher
levels of nicotine dependence, and lower self-efficacy
related to quitting (Siahpush, McNeill, Borland, & Fong,
2006). Historical lack of access to smoke-free housing
may also contribute to lower cessation rates among this
population, though a recent policy by the Department of
Housing and Urban Development requiring all public
housing to become smoke-free may attenuate this particular barrier (Geller, Rees, & Brooks, 2016).
Population level mass media campaigns are a wellestablished, effective strategy for reducing tobacco use
prevalence (Durkin, Brennan, & Wakefield, 2012) and
are recommended as a tobacco control best practice
(Centers for Disease Control and Prevention [CDC],
2014). Mass media campaigns use various communication channels, including television, radio, print, and/or
out-of-home (e.g., billboard) advertising (Durkin et al.,
2012). Campaigns are most effective when integrated
with a comprehensive tobacco control program including community interventions and cessation activities
(CDC, 2014). However, the evidence is somewhat mixed
about the impact and optimal use of mass media to
promote use of cessation programs and cessation among
tobacco users with low SES (Durkin et al., 2012;
Niederdeppe, Kuang, Crock, & Skelton, 2008), but possible differences in effectiveness for this group may be
related to campaign exposure, motivational response,
and/or opportunities to sustain long-term cessation
(Niederdeppe et al., 2008).
The CDC (2014) highlights the importance of creating
messages that resonate with a given priority audience,
and there is evidence that ads focusing on negative
health consequences and using personal testimonials,
graphic imagery, and/or negative emotion may contribute to overall campaign effectiveness among low-SES
smokers (Durkin et al., 2012; Niederdeppe, Farrelly,
Nonnemaker, Davis, & Wagner, 2011). The CDC-funded
national mass media Tips From Former Smokers (Tips)
advertising campaign used this approach and has been
associated with increases in quitline call volume across
most states and demographic groups (Zhang, Malarcher,
et al., 2015; Zhang, Vickerman, Malarcher, & Carpenter,
2015), resulting in increases in population-level quit
attempts (McAfee, Davis, Alexander, Pechacek, &
Bunnell, 2013). However, the effectiveness of the Tips
campaign specifically on smokers with low SES has not
been established.
Rimal and Lapinski (2009) describe a health communication framework characterized by James Carey
as involving both the transmission of messages (i.e.,
transmission view) and the receipt and evaluation of
messages by individuals (i.e., ritual view). This dual
view of communication asserts that individual and
social factors (e.g., personal experiences, efficacy
beliefs, social norms) influence the communication
efforts people encounter and the meaning they take
away from those communications (Rimal & Lapinski,
2009). This framework suggests that improved understanding of the factors that influence how low-SES
smokers evaluate tobacco control ads may support the
development of messages that more effectively engage
this population.
To that end, we present findings from focus groups
conducted as part of an independent evaluation of the
Connecticut Tobacco Control Program designed to
inform the program’s mass communication strategies
and other cessation resources. Connecticut launched
an 11-month tobacco control campaign in November
2013 that included a mix of English and Spanish language Tips ads on TV, radio, print, online, and out-ofhome venues. All ads were tagged with the quitline
number and website, intending to drive callers to the
Connecticut Quitline, which offers tobacco users in
Connecticut five counseling calls and 2 weeks of free
nicotine replacement therapy (NRT). Connecticut’s
mass communication efforts attempted to reach several
priority populations, including tobacco users with low
SES, and focus group recruitment was designed to
achieve representation from these populations. In our
initial analysis of these data, which focused on questions specific to program planning and evaluation, we
identified an unanticipated body of data relating to
how participants’ experiences and beliefs influenced
their receipt and evaluation of tobacco cessation media
messages.
Method
>>
Focus groups were designed to inform program
planning for the Connecticut Tobacco Control Program,
rather than as data collection for a formal qualitative
study. Methodological decisions about recruitment and
focus group implementation reflect the primary purpose of the groups; decisions related to data analysis
are informed by a thematic analysis approach (Braun &
Clarke, 2006), adapted to address the limitations inherent in conducting a formal qualitative analysis on data
collected in the context of real-world public health
program planning.
McCullough et al. / PERCEPTIONS OF TOBACCO CONTROL MEDIA CAMPAIGNS
551
Participant Recruitment
Analysis
Eligible participants were adults age 18 or older
who reported current cigarette smoking; eligibility criteria were intentionally broad to facilitate adequate
participation. Focus groups were held over a 2-day
period in September 2014. Recruitment flyers and
radio ads directed interested participants to complete
eligibility screening via a website or a toll-free number.
One member of the research team conducted in-person
recruitment the week prior to focus groups by passing
out flyers, completing eligibility screenings, and registering participants on-site, focusing on high-traffic public areas providing resources that low-SES individuals
are likely to access, such as bus stops and libraries.
Each participant signed a printed consent form on-site
prior to beginning the focus group and received a $50
incentive. The study protocol was approved by the
institutional review board at the University of North
Carolina at Chapel Hill (Study No. 4-0651).
All focus groups were audiotaped and transcribed
verbatim and imported into ATLAS.ti 6.2 (Scientific
Software Development GmbH). Four research team
members were involved in an iterative review process of
the data, using an inductive thematic analysis approach
(Braun & Clarke, 2006). Two of these team members
attended the focus groups as note-takers. Team members
first read through two transcripts to become familiar
with the data, followed by team discussion to clarify the
research question and develop initial codes. Team members read through the same two transcripts a second and
third time, with a team meeting after each to review coding and finalize the codebook to add or remove codes
that did not add value to the analytic process. A fourth
round of reading involved each team member coding
two new transcripts with the finalized codebook. Two
team members then reviewed each transcript to merge
coding and reach consensus on different applications of
codes as needed. Inconsistencies in coding between
team members were resolved through discussion. The
four analysis team members collaboratively reviewed
final coding to create a thematic map of the codes, as
described by Braun and Clarke (2006), which was used
as a basis for defining and refining themes across the
data set. Identification of overarching themes was based
on consensus that the idea was expressed across multiple participants and groups and that it captured an
important part of the narrative of how low-SES smokers
receive and evaluate tobacco cessation media messages.
Focus Groups
Eight focus groups, each including between 10 and
16 participants, were held at public library locations.
Sessions were conducted by a third party moderator
with extensive focus group experience; the moderator
was not involved in data analysis or interpretation.
Focus groups were semistructured, based on a question
guide developed by study authors. Groups lasted
between 60 and 90 minutes. Initial questions focused
on barriers and motivators for quitting and assessing
awareness and opinions of cessation resources available, specifically the telephone quitline. Participants
were asked to recall any quit smoking or smoking prevention advertisements they had ever seen and asked
to describe how they felt when they saw the ads and
how the ads affected their thoughts about smoking or
quitting smoking. Participants were then shown five
television ads from various state-level campaigns (2009
ad from North Carolina’s Tobacco. Reality. Unfiltered
campaign, 2009 ad from Washington State’s Dear Me
campaign, 2012 ad from New York City’s Suffering
Every Minute campaign, and a 2009 North Carolina
Quitline promotion campaign) and one ad from the
2013 national Tips campaign. Ads were shown one at a
time with a set of discussion questions after each ad.
Ads were selected based on no-fee availability from the
CDC Media Campaign Resource Center and represented
a mix of themes and tones (i.e., some used graphic
health imagery while others focused on self-efficacy or
the benefits of quitting). To our knowledge, no studies
have been published investigating the impact of these
campaigns on differing socioeconomic groups.
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HEALTH PROMOTION PRACTICE / July 2018
Results
>>
A total of 98 adults who reported current cigarette
smoking participated in the eight focus groups (Table 1).
Demographic data were missing for 21% to 33% of participants due to refusals and difficulty monitoring data
completion during in-person recruiting. Though factors
related to SES were not a part of eligibility criteria, most
participants reported lower educational attainment
(55% reported high school/GED or less). Only 27% of
participants indicated they had “enough money to pay
the bills,” and discussion of financial stressors was common across all groups. Discussion across specific topics
centered around two themes that appeared to influence
participants’ evaluation of ads: skepticism about cessation media messages and resources and perceived barriers to quitting.
Skepticism
Many participants expressed skepticism about the
content of tobacco control ads, the role of the tobacco
Table 1
Summary of Participant Demographics (N = 98)
Demographic Characteristic
n (%)
Gender
Female
Male
Unknown
Age, years
18-24
25-34
35-54
55+
Unknown
Race
White
Black or African American
Other
Unknown
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unknown
Sexual orientation
Heterosexual/straight
Lesbian, gay, or bisexual
Other
Unknown
Education level
Less than high school
High school/GED
Some college/college or more
Unknown
Financial situation
Have enough money to pay the bills
Have to cut back on things to pay the bills
Have trouble paying the bills
Unknown
27 (27.6)
50 (51.0)
21 (21.4)
5
22
36
14
21
(5.1)
(22.5)
(36.7)
(14.3)
(21.4)
17
29
25
27
(17.3)
(29.6)
(25.5)
(27.6)
23 (23.5)
41 (41.8)
34 (34.7)
doubt about the legitimacy of testimonial style ads,
asserting that these ads tried to pass off actors as “real”
people sharing their stories and that the health effects
portrayed were rare cases, overly extreme, or unlikely
to have been caused solely by smoking.
I mean, I seen a lot of people that passed away
with trachs because it was cancer. You know, it
wasn’t some that smoked cigarettes, but it was
because of cancer. They had other . . . form[s] of
cancer so how would you know? Like, they could
be just using people that are saying like what their
illness is, but it’s not really caused from smoking.
(Female, Group 4)
Distrust of the Tobacco Industry and Government. Participants also expressed distrust and negative attitudes
about the tobacco industry’s and government entities’
perceived roles in sponsoring tobacco control campaigns. Some discussion was given to the idea that
tobacco control efforts may be sponsored by the tobacco
industry, making ads untrustworthy due to conflicts of
interest between maintaining sales and encouraging
people to quit. Other discussion focused on perceptions that government entities are too invested in maintaining revenue from tobacco sales and/or too connected
to the tobacco industry to truly want people to quit
smoking.
59
6
1
32
(60.2)
(6.1)
(1.0)
(32.7)
17
37
17
27
(17.3)
(37.8)
(17.3)
(27.6)
27
8
23
40
(27.6)
(8.2)
(23.5)
(40.8)
A related vein of discussion focused on the perception that large amounts of money from tobacco sales
revenue and tobacco industry lawsuits are available for
campaigns but that only a bare minimum is allocated,
resulting in ads that are lower quality and ineffective.
industry and governmental agencies in sponsoring
media messages and promoting continued tobacco use,
and the safety and efficacy of cessation supports. Such
skepticism appeared to be salient in how they evaluated tobacco control media messages.
Safety and Efficacy of Cessation Supports. Finally,
skepticism about tobacco control media messages
appeared to be intertwined with skepticism about cessation supports, such as the quitline and tobacco cessation pharmacotherapy. Lack of knowledge about
available supports played some role in the skepticism,
with most participants indicating they did not know
what the quitline offered or had never heard of the quitline, despite the quitline number being included in
many of the ads participants recalled seeing.
Content of Tobacco Control Ads. Participants’ skepticism about the content of tobacco control ads focused
particularly on ads depicting the serious health consequences of smoking. Some participants expressed
If you make it illegal, I mean not to be—the government makes too much money on cigarettes for them
to stop selling cigarettes. The government, I mean,
you’ve got medical. You’ve got doctors. You’ve got,
you know, there’s too much money involved for
them to say let’s stop smoking. (Male, Group 2)
McCullough et al. / PERCEPTIONS OF TOBACCO CONTROL MEDIA CAMPAIGNS
553
I now realize that I’ve seen [the quitline number],
but I’ve overlooked it so much. You know what I
mean? Because I’ve definitely seen commercials
with the quitline number, but thinking about it
when you first started talking about it, it didn’t
register in my brain. (Male, Group 5)
Even after services were described by the moderator,
many participants expressed skepticism that such services would be helpful or judgment-free.
Skepticism about cessation supports was also related
to feeling that such resources were not truly accessible
or doubt that supports provided for free (e.g., coaching,
2 weeks of free nicotine patches) would be sufficient to
meaningfully aid in long-term quitting. Skepticism
about cessation medication was also related to uncertainty or misinformation about the safety and efficacy
of NRT and prescription cessation pharmacotherapy.
Barriers to Quitting
Stress. Participants described multiple barriers to quitting, which were closely linked to or embedded in participants’ social and environmental contexts.
Participants described living in highly stressful circumstances and identified stress as a primary barrier to
quitting. Participants described a cyclical process about
how another barrier to quitting—the lack of societal
support and resources for tobacco use cessation—led to
more stress. At the same time, smoking was described
as an important, or even the only, perceived source of
coping with stressors and was used as a substitute or
replacement for other stress responses or as a type of
self-medication.
[Smoking] is anger management. It’s medicinal in
my mind. Helping my anger management when I’m
stressed, I’m angry. Instead of doing what I want to
do, I’ll smoke a cigarette . . . like if I’m depressed
or something like that. (Male, Group 2)
Social Environment. Many participants described their
motivation to quit smoking being undermined by support networks and social environments (e.g., families,
recovery groups) that are saturated with other people
who smoke. Some participants described how smoking
was a normative part of their family culture and discussed the lack of social support for quitting that exists
in their environments where smoking prevalence is high.
It’s a habit . . . if you have other people around you
that smoke and you’re trying to quit, it’s not going
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HEALTH PROMOTION PRACTICE / July 2018
to be easy, because you’re not smoking it, but
you’re smelling it constantly, you’re seeing other
people smoking. (Female, Group 7)
Smoking was so ubiquitous in many participants’
lives that they perceived no way to avoid it. Indeed,
several participants shared that their only successful
quit attempts had occurred during incarceration when
their environments were mandated to be tobacco-free,
describing quick relapse to smoking after being released.
Addiction. Many participants focused on the role addiction played in their perceived inability to quit, describing addiction as an insurmountable barrier. There was
consensus across most participants that their relationship with smoking was rooted in addiction, and some
participants shared stories of how quitting smoking was
more difficult for them than quitting other drugs.
It’s physically addictive too, you know. The physical addiction to it is intense. I’ve dealt with other
addiction issues in my life, and that is by far the
hardest one. (Male, Group 5)
Participants described a disconnect between the
tobacco control messages they hear and their everyday
struggle with nicotine addiction; participants perceived
messages as not acknowledging the seriousness of their
addiction and the help they need to overcome that
addiction. A few participants even expressed a desire
for a rehabilitation program similar to treatment for
other drugs, such as Alcoholics Anonymous, specific
for nicotine addiction
See Table 2 for a list of illustrative quotes around the
two themes.
Discussion
>>
Our findings support and expand on previous
research, suggesting that population-based tobacco
control media campaigns may be less effective among
smokers from lower SES populations (Niederdeppe
et al., 2011). Most participants had been exposed to one
or more cessation media campaigns, suggesting that
campaign reach may not be the sole driver of effectiveness. Our findings suggest that a more nuanced response
among lower SES smokers, in which skepticism and
significant perceived barriers to quitting contribute to
dismissal of and/or resistance to population-based
media campaigns.
For many participants in these groups, the graphic and
negative aspects of the ads did not appear to translate into
Table 2
Qualitative Themes Regarding Perceptions of Tobacco Cessation Media Messages (Sampling of Illustrative Quotes)
Domain
Skepticism about
messages
Qualitative Themes
Content of tobacco
control ads
Distrust of the
tobacco industry
and government
Safety and efficacy of
cessation supports
Illustrative Quotes
“I mean, I seen a lot of people that passed away with trachs because it
was cancer. You know, it wasn’t some that smoked cigarettes, but it
was because of cancer. They had other . . . form[s] of cancer so how
would you know? Like, they could be just using people that are saying
like what their illness is, but it’s not really caused from smoking.”
(Female, Group 4)
“Sometimes I feel indifferent because I don’t know what that person
[from the ad] could have done to even cause that level of cancer. They
could have been smoking crazy packs a day which is not something I
do.” (Male, Group 6)
“I feel like with the commercials and everything, all the movies we see
and everything, they could be actors. Even if they do get somebody
real, we don’t really know that because we know everything is
fantasized on TV most of the time anyway and special effects we see
all the time. I mean you could take somebody and make them look like
whatever you want to make them look like for special effects.” (Male,
Group 6)
“Tobacco is a big business, just like insurance . . . big business, big
money, they got too much power . . . any time there’s big money in
stuff, cigarettes are going to be around forever.” (Male, Group 8)
“It’s a manmade, I mean, it’s part of government. The government put
that out there. I mean, they could never make money unless they put a
product out there that they know people’s going to try it, and they’re
going to get addicted to it.” (Female, Group 4)
“The people that’s making money off [tobacco], they don’t want you to
quit.” (Male, Group 7)
“If you make it illegal, I mean not to be—the government makes too
much money on cigarettes for them to stop selling cigarettes. The
government, I mean, you’ve got medical. You’ve got doctors. You’ve
got, you know, there’s too much money involved for them to say let’s
stop smoking.” (Male, Group 2)
“. . . I don’t want to talk to someone who has no idea of what I’m going
through. You could have learned and have book smarts about what
smoking is, but if you’ve never smoked you don’t know.” (Male, Group 5)
“It’s not that we don’t want to quit. It’s that we don’t have the resources
or the help.” (Female, Group 6)
“They [nicotine patches] have a chemical that will help you stop
smoking cigarettes, but how would you know if it’s going to harm you
more than the cigarettes?” (Female, Group 4)
“I now realize that I’ve seen [the quitline number], but I’ve overlooked it
so much. You know what I mean? Because I’ve definitely seen
commercials with the quitline number, but thinking about it when you
first started talking about it, it didn’t register in my brain.” (Male,
Group 5)
“[The quitline] is going to give you 2 weeks [of patches] but what’s
going to happen then? Then how much is it going to cost you?” (Male,
Group 6)
(continued)
McCullough et al. / PERCEPTIONS OF TOBACCO CONTROL MEDIA CAMPAIGNS
555
Table 2 (Continued)
Domain
Barriers to
quitting
Qualitative Themes
Stress
Social environment
Addiction
Illustrative Quotes
“When you have a Newport, you can actually get a high. Like you get
that kind of a high a lot of times. And sometimes when you smoke a
Newport, you’d be mad, upset, stressed or whatever—it calms you
down.” (Male, Group 5)
“The stress builds up so much to the point I’m not even thinking about
calling [the quitline]. I probably will be thinking about cigarettes.”
(Male, Group 8)
“[Smoking] is anger management. It’s medicinal in my mind. Helping
my anger management when I’m stressed, I’m angry. Instead of doing
what I want to do, I’ll smoke a cigarette . . . like if I’m depressed or
something like that.” (Male, Group 2)
“It’s a habit . . . if you have other people around you that smoke and
you’re trying to quit, it’s not going to be easy, because you’re not
smoking it, but you’re smelling it constantly, you’re seeing other
people smoking.” (Female, Group 7)
“I left the cigarettes at the house and don’t want to bring them with me
because I’m trying to quit and I’ll be downtown or I’ll be somewhere
and I’ll see somebody smoking, like, ‘Dang, I wish I was smoking.’”
(Female, Group 7)
“The thing about quitting is I could go like a couple of days without a
cigarette but the second you go outside because it’s like everywhere so
it’s not that easy because to be honest if you enjoy cigarettes.” (Male,
Group 6)
“I grew up in a household where everyone smoked, and as a kid I
remember thinking to myself eventually I’m going to do that, or I want
that, or is that what I’m going to do when I’m older, is that what
growing up is all about? And when I was in school and my friends
were hanging out behind the tennis court smoking, I was like, oh so
it’s my time to grow up.” (Female, Group 7)
“It’s physically addictive too, you know. The physical addiction to it is
intense. I’ve dealt with other addiction issues in my life, and that is by
far the hardest one.” (Male, Group 5)
“Cigarettes is not something that people say okay I just kind of smoke.
It’s an addiction that’s really hard to deal with. It’s like being an
alcoholic, being a drug addict.” (Female, Group 6)
“It’s like binge drinking, I mean, I pick up—I don’t know why I pick up,
I pick up because I feel like picking up a cigarette. And if you ask me
what it does to me, I can’t say, I just—all I know is I’m addicted and I
want to stop.” (Male, Group 7)
“And as a fact for rehab, I was there for alcohol, and the alcohol I beat
in 2 weeks, I couldn’t stop thinking about cigarettes. The cigarette was
more addictive for me, personally.” (Male, Group 8)
perceived effectiveness. Indeed, these aspects of the
ads contributed to feelings of skepticism about message
content, which some participants described as exaggerated or unrealistic. This skepticism contributed to participants evaluating ads with a self-exempting lens,
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HEALTH PROMOTION PRACTICE / July 2018
focusing on ways in which the people and circumstances depicted in ads do not reflect their reality. As
such, the credibility of both the ads’ explicit (e.g.,
smoking leads to severe negative health consequences)
and implicit (e.g., this could happen to you) messages
was undermined. These findings are consistent with
self-exempting, or risk-minimizing, beliefs that arise
when an individual’s actions conflict with his or her
knowledge about those actions (i.e., cognitive dissonance theory; Guillaumier et al., 2016). Many participants in these focus groups expressed “skeptic”
self-exempting beliefs (i.e., they do not believe the
harms of smoking portrayed in messages are real), as
well as “bulletproof” beliefs (i.e., they will not be
affected by the harms of smoking portrayed in messages, often because they perceived themselves as
smoking less than the actor portrayed; Oakes et al.,
2004). As seen in our focus groups, smokers with lower
educational attainment are more likely to hold selfexempting or other “disengagement” beliefs (Oakes
et al., 2004), which have been linked to lower motivation and intentions to quit (Kleinjan, van den Eijnden,
Dijkstra, Brug, & Engels, 2006; Oakes et al., 2004).
Our results are consistent with previous research that
indicates perceived credibility of the source of tobacco
control campaigns plays an important role in campaign
effectiveness (Schmidt, Ranney, Pepper, & Goldstein,
2016). Trust in the source of health information is suggested to affect how that information is received, processed, and acted on (Avery, 2010), and trustworthiness
has been identified as a key component of source credibility (Schmidt et al., 2016). In some groups, there was
confusion about the source of messages, with discussion given to the idea that some messages are sponsored
by the tobacco industry and are therefore neither trustworthy nor credible. The idea that messages encouraging participants to quit might be sponsored by the same
entities that are profiting off their addiction appeared to
leave some participants feeling resigned or disempowered, suggesting that this kind of misinformation may
further undermine message effectiveness by contributing to reduced self-efficacy for quitting. This perception
is not entirely unfounded, considering that the tobacco
industry has historically targeted low-SES and minority
groups (Balbach, Gasior, & Barbeau, 2003; Yerger,
Przewoznik, & Malone, 2007).
Other participants correctly identified governmental
agencies as the source of tobacco control campaigns but
believed that government entities were invested in
ensuring that people continue to smoke in order to satisfy the government’s relationships with the tobacco
industry and/or to continue bringing in revenue from
tobacco sales. As such, government entities were perceived to be untrustworthy as sources of credible, motivating messages about quitting smoking. Our results
suggest that clearly communicating the source of
tobacco control campaigns and working to correct misperceptions about the relationship between the tobacco
industry and governmental public health and regulatory agencies may contribute to increased trust in these
agencies among low-SES smokers. As such, according
to Carey’s transmission and ritual view of communication, addressing the historical practice of targeting lowSES and minority individuals by the tobacco industry
(Balbach et al., 2003; Yerger et al., 2007) and correcting
misinformation related to message sponsorship may
help alter the selective perception of the message transmitted, or the meaning individuals derive from the
message (Rimal & Lapinski, 2009).
Lack of knowledge and skepticism about the accessibility, efficacy, and safety of evidence-based cessation
supports like the quitline and cessation pharmacotherapy also appeared to influence participants’ evaluation of and receptivity to tobacco control media
campaign messages. Distrust of quitline services
(Sheffer, Brackman, Cottoms, & Olsen, 2011) and beliefs
that evidence-based treatments are not more effective
than other methods (McMenamin, Halpin, & Bellows,
2006); that cessation pharmacotherapy is addictive,
dangerous, and not effective (Cummings et al., 2004;
Wiltshire, Bancroft, Parry, & Amos, 2003); and that cessation treatments are difficult to access (McMenamin
et al., 2006; Roddy, Antoniak, Britton, Molyneux, &
Lewis, 2006) are well documented among low-SES
smokers. Our findings add to this literature and suggest
that negative perceptions and lack of knowledge about
evidence-based cessation supports may lessen the
potential motivational impact of cessation messages.
Additional research is needed to more clearly understand this process and to determine how mass media
messages can communicate information about cessation treatment resources in a way that reduces misperceptions and skepticism among low-SES smokers.
Increasing the duration of time for which quitline numbers or other resources are displayed on ads, including
a brief description about how quitlines work and brief
statements debunking common myths about the safety
and efficacy of NRT, and offering longer courses of free
NRT, may be effective strategies for future media campaigns to consider. Increasing knowledge around the
availability of tobacco cessation resources such as the
quitline and the effectiveness of these resources can
increase self-efficacy beliefs among tobacco users,
resulting in a more positive selective perception of
media campaign messages (Rimal & Lapinski, 2009).
Findings suggest that participants’ personal experiences, particularly related to stress and addiction, and
social norms around smoking in low-SES populations
also affect the selective perception of tobacco control
media messages (Rimal & Lapinski, 2009). Skepticism
about cessation resources was closely linked to the
McCullough et al. / PERCEPTIONS OF TOBACCO CONTROL MEDIA CAMPAIGNS
557
ways in which smoking permeates their social environments, the importance of smoking as a critical stress
management tool, and strong addiction to nicotine.
These perceived barriers align with other documented
contributors to tobacco use and cessation disparities
among people with low SES: lack of social support for
quitting, more prosmoking social norms, higher stress
environments, greater reliance on smoking as a coping
mechanism, and stronger addiction (Hiscock et al.,
2012). The extent to which participants talked about
these barriers to quitting suggests that these barriers
may mediate the motivational impact of messages, even
when the messages are attention-grabbing and successfully elicit negative emotional reactions. Barriers
related to low-SES smokers’ environments and experiences with stress are likely strongly influenced by more
“upstream” challenges, such as low wages and lack of
affordable housing, that are beyond the reach of tobacco
control programs. However, it may be important for
media campaigns to acknowledge these barriers to better reflect the realities of low-SES smokers’ lives and
challenges with quitting (i.e., their selective perception) and potentially reduce resistance to cessation
messages (Rimal & Lapinski, 2009).
Participants’ perceptions about nicotine addiction
as a significant barrier to quitting reflect evidence that
low-SES smokers are more highly addicted than higher
SES smokers and that higher addiction is related to
reduced likelihood of quitting (Hiscock et al., 2012).
Some participants expressed feeling frustrated that
tobacco control messages do not adequately reflect the
realities of nicotine addiction, a disconnect that may
increase the chances of low-SES smokers viewing ads
through a self-exempting lens. The belief that quitting
smoking is as difficult as or more difficult than overcoming other addictions contributed to a feeling among
some participants that the kind of help they would
need to quit smoking (e.g., detox programs or long-term
support programs) is not available, contributing to
skepticism about available cessation resources. As
such, believing that nicotine addiction is an insurmountable barrier to quitting appeared to reinforce
resistance to cessation-focused campaign messages. It
may be important for tobacco control media campaigns
to increase low-SES smokers’ efficacy beliefs by validating their experience with addiction and communicating that nicotine addiction can be overcome with
available evidence-based treatments.
Limitations
The focus groups were originally conducted to
inform the Connecticut Tobacco Control Program mass
558
HEALTH PROMOTION PRACTICE / July 2018
communication strategy, with a focus on program planning and evaluation. As such, we used a convenience
sample of adult smokers, with no specific inclusion
criteria based on SES, and our participant demographic
information was incomplete for a substantial number of
participants. Based on available data, though, the
majority of participants had low education levels and/
or were struggling financially and thus represented the
intended population. Though qualitative data are not
intended to be generalizable, we recognize that results
from this particular study may not necessarily be applicable to all low-SES smokers in the United States.
Additional studies can help clarify the extent to which
skepticism and barriers to quitting influence the receptiveness of tobacco control media messages among lowSES smokers across the country.
Conclusions
As tobacco use is increasingly concentrated in lowSES populations, it is critical that tobacco control mass
media campaigns are appropriately targeted to this
priority group. Findings from our focus groups add to
the body of research indicating that tobacco control
messaging may reach lower income smokers but does
not appear to effectively motivate this group to quit.
Our findings suggest that skepticism about cessation
message content, perceived sources of campaign ads,
and cessation supports as well as barriers to quitting
related to stress, social contexts, and addiction play a
role in how low-SES smokers evaluate tobacco control
media messages. Further research examining the ways
in which media campaigns can address skepticism and
barriers to quitting among low-SES smokers may inform
more effective campaigns.
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